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Signed <br />Print Name <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/SiteInformation <br />PARTMENT USE ONLY <br />134 1-p-tIty <br />Date Issued: kif.ZA, I/8 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Jo County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company STAFF GEOLOGIST / AGE <br />Date 1/17/18 Ren) 0th <br />SANAAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness grows here. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 3 East 11th Street <br />Cross Street Holly Drive ApN 2i3-369-18 <br />Property Owner* Levand Family Trust/ Levand Bright Family Trust - Trustees, Paula Levand & Joan Konkel <br />Phone (209) 467-1006 <br />Phone (661)904-2133 <br />City/State/Zip Tracy, California 95304 <br />Address 24692 Sand Wedge Lane <br />C-57 Contractor Slagle Drilling Corporation <br /> <br />City/State/Zip Valencia, California <br /> <br />License# 1046151 Phone (209) 467-1006 <br />City/State/Zip Rancho Cordova, California <br />License# 680227 Phone (209) 467-1006 <br />City/State/Zip STOCKTON, CA 95215 <br />Address 3369 Fitzgerald Road Suite B <br />Consultant/Sub-Contractor AGE <br /> <br />Address 837 SHAW ROAD <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER _INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1)11 MONITORING 4 4 HOLLOW STEM BORING DEPTH 20 (3) & 40' (1) 51 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />El EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 8.25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />0 SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: ID STEEL 121 PVC 0 OTHER <br />EJ SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes In No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION (Air Spam, Ozone) 'HAND AUGER GROUT SEAL DEPTH 1.5. 8, 30.5. TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ID PIPE <br />OTHER 0 OTHER: GROUT SEAL PUMPED? ID Yes 18] No (Note: Maximum Freetall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs MW-1 through MW-4 GROUT SPECIFICATIONS PORTLAND TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />ID MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: ** See attached Work Plan and site plan ** <br />FA Name Levr44,41 8 v•I 1.4-- erup."4,1 FA Address 3 ri..8.1.. i I fl". s-j— F A# co Llt il I PR# 0.241 Er 1 -7 <br />FA PE .2---1,(i0 <br />WP Reviewed By <br />I-• ' Y Work Plan Date glee) j--e_A t g <br />0 C-57 g6157 Authorization for Other to Sign Permit 11:14/Orker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement Erre-ad Agency Approval 11}4 <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit ?fro I 11) $152x Ai tuaw 2.51'6 L)( 'k' k V-, POO 39 238 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />„Je .2443 cv, 0243 fLtst cc 4-tAto oc